The concept of safety as a box-checking enterprise, where we start and finish, is lethal to patients of the future.”

3) Incentive theory:

Berwick's roots in working directly with Dr. W. Edwards Deming show here. Healthcare professionals have strong intrinsic motivation to not harm patients. As Deming, Alfie Kohn, Dan Pink, and others would point out, more incentives or better-designed incentives aren't the solution we need.

4) Metrics glut:

I agree that most organizations' executives have too many metrics — not just around patient safety and not just in healthcare). Remember, KPI stands for KEY Performance Indicators.

“We have to remove the chaos,” said Berwick, who also served as administrator for the Centers for Medicare & Medicaid Services. “We know how to do it, we've made progress. In the next 20 years, I don't think we should be able to say we've learned what we need to know, I think we need to say, now what do we need to do?”

There's been progress… in pockets throughout healthcare (as I've collected some stats and stories here). We need more progress, more widely. Nobody's perfect, but some organizations have made great strides, while others lag behind.

When I asked Paul O'Neill once what held back patient safety progress in healthcare, he said, without missing a beat: “Lack of leadership.”

Hear my podcast with him, where he said:

“I honestly think the skill shortage in our society, maybe in the world of civilized people, is real leadership.”

“I would urge Boards of Directors of health and medical care institutions, hospitals, and nursing homes to ensure the day-to-day operational leader is supportive of the idea of establishing theoretical limit goals for everything that goes on in their institutions. Because I think if Boards of Directors urge the people who are day-to-day responsible for care delivery, it might provide some stiffening of the backbone of those who are supposed to lead institutions to habitual excellence.”

Facebook reminded me, also, that it was a year ago yesterday that I blogged about the Emily Jerry story as told by her father Chris on Fox News: